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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 17-21

Application of three-dimensional printing in the resection of giant tumor of the thoracic cavity and the reconstruction surgery of chest wall


1 Institute of Digital Medicine, Biomedical Engineering College, Third Military Medical University, Chongqing 400038, China
2 Department of Cardiothoracic Surgery, Southwest Hospital, Third Military Medical University, Chongqing 400038, China
3 Department of Computer Science, Biomedical Engineering College, Third Military Medical University, Chongqing 400038, China

Date of Web Publication11-May-2016

Correspondence Address:
Shaoxiang Zhang
Institute of Digital Medicine, Third Military Medical University, Chongqing 400038
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2226-8561.182297

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  Abstract 

Objective: To evaluate, the feasibility and efficacy of three-dimensional (3D) digital navigation, 3D design, and 3D printing in the surgical treatment of giant tumors in thoracic cavity. Patients and Methods: A 62-year-old male patient had a giant tumor in the left thoracic cavity. The tumor constricted the left lobe with the left chest wall being involved. We performed high-precision consecutive thin-sectional computed tomography (CT) scanning and obtained the 3D model of the tumor, lung, pulmonary, tracheobronchial tree, sternum, ribs, and costal cartilage with self-developed 3D image processing software. Before surgery, we also carried out digital navigation, printed out the tumor and the chest wall that is intended to be reconstructed, and developed the surgery program for the giant tumor. At the same time, 3D chest wall titanium was produced based on 3D printing. We performed giant tumor resection and sutured the titanium plate to the chest wall of the patient to repair the chest wall defect. After surgery, we performed CT scans and 3D reconstruction in order to determine the efficacy of surgical treatment. Results: The results showed that we successfully designed the repair surgery program for chest wall defect after the tumor resection. Titanium based on the 3D printing-assisted design completely fit the chest wall defect. Blood loss was significantly reduced compared to conventional titanium suture. There were fewer postoperative complications, and patient recovery was fast. Conclusion: We conclude that 3D printing-assisted resection of tumors in the thoracic cavity and chest wall reconstruction contributes to developing surgery program and performing complex thoracic surgery, which improves the efficacy of surgery, shortens the operation time, reduces the abrasion of conventional steel implant to the residual sternum, ribs, chest wall muscle and pleura, decreases the bleeding, abnormal breathing, and achieves the developmental shift to digital and personalized cardiothoracic surgery.

Keywords: Giant tumor of thoracic cavity, reconstruction surgery of chest wall, three-dimensional printing


How to cite this article:
Wu Y, Wu W, Wang H, Xiao Y, Zhang S. Application of three-dimensional printing in the resection of giant tumor of the thoracic cavity and the reconstruction surgery of chest wall. Digit Med 2016;2:17-21

How to cite this URL:
Wu Y, Wu W, Wang H, Xiao Y, Zhang S. Application of three-dimensional printing in the resection of giant tumor of the thoracic cavity and the reconstruction surgery of chest wall. Digit Med [serial online] 2016 [cited 2019 Oct 17];2:17-21. Available from: http://www.digitmedicine.com/text.asp?2016/2/1/17/182297


  Introduction Top


Three-dimensional (3D) printing has attracted wide attention in both scientific community and industry. In the August of 2012, the US President Barack Obama allocated $30 million to establish a national research center on 3D printing additives and planned to invest $500 million in 3D printing technology.[1] China's recent National 863 Program, the National Science and Technology Support Program, and high-end equipment and key technology projects explicitly listed 3D printing as a priority for financial support.

3D printing has been widely applied in medical field, especially in the surgical preoperative diagnosis and surgical rehearsal.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] Clinical doctors can visually observe, diagnose, prepare surgical plan directly, and perform surgical rehearsal on the 3D-printed model, which will help them be aware of the conditions before the surgery. However, application of 3D printing in surgical treatment has not been reported to a greater extent. Currently, 3D printing is mainly used for surgery-assisting devices, for example, operation guide plate,[2],[5],[13] while 3D printing of the implanted materials was seldom reported. This is mainly due to the controversy on the hardness, stability, and quality of 3D printed products. Furthermore, there are very few reports on the application of 3D printing in cardiothoracic surgery.

The purpose of this study was to develop 3D printing-assisted thoracic giant tumor resection and chest wall reconstruction surgery on patients with chest wall defects. We expect to achieve digital and personalized therapy in the field of cardiothoracic surgery.


  Materials and Methods Top


Patients

A 62-year-old male patient with a giant tumor on the left thoracic cavity was selected for this study. The tumor has invaded the left side of the chest wall, and pathological examination diagnosed it as invasive fibrous pleural tumors with low-grade malignancy.

Image segmentation and three-dimensional reconstruction

High-precision thin-sectional computed tomography (CT) scan was performed with a scanning resolution of 512 × 512, pixel size of 0.684 × 0.684, and layer spacing distance of 0.7 mm. The patient's CT data were subsequently imported into Amira commercial software. Data on pulmonary vessels, ribs, cartilage, sternum, lung, and the giant tumor were semi-automatically segmented, and 3D reconstruction was performed. 3D design was carried out for the chest wall based on the characteristics of the opposite sternum and the range with tumor involvement. The design was expected to highlight the tumor and the 3D model of the chest wall. The file was saved as STL format.

Three-dimensional printing

3D printing was performed for the tumor and the chest wall based on the 3D reconstructed model. We used any print medium-sized 3D printer (model: UN-3D-S2) provided by Uniroyal Technology Co., Ltd. (Qingdao, China). Fused deposition molding was applied with a printing thickness of 0.1 mm and a maximum printing size of 400 mm × 300 mm × 200 mm. Printing material was an acrylonitrile butadiene styrene resin plastic thread, and the support material was reprap/mendel dissolvable plastic thread. After 3D printing was completed, we removed supporting material and performed the surface smoothing treatment.

Molding of the three-dimensional printed auxiliary plate

3D model was printed out, and surgery overview was performed, and surgery program was designed. Subsequently, 3D design of titanium plate was performed using the existing 3D printing materials.

Implant of three-dimensional printed titanium plate

The giant tumor in the patient's thoracic cavity was resected, with a resection area including the entire tumor, ribs, cartilage, and intercostal muscle that were invaded by tumors. We then sutured the 3D titanium plate in the defected area of the chest wall.

Computed tomography exam

In the 10 days after surgery, we performed thin high-precision CT scan with a resolution of 512 × 512 and interlayer spacing distance of 0.7 mm. 3D reconstruction of CT scan was performed to review the titanium anastomosis.


  Results Top


We successfully reconstructed the 3D model of the giant tumor and its adjacent structures including pulmonary vessels, lung, bronchus, ribs, sternum, costal cartilage, and the chest wall. 3D visualization of the tumor shape and its relationship with its adjacent structures was also performed. The results showed that the size of the tumor was huge, and the size was 30 cm × 25 cm × 15 cm, which pushes the left lung upward, and the lung was severely invaded and deformed [Figure 1]. Meanwhile, the tumor has invaded the left lower portion of the chest wall. The structures with tumor invasions include 5th–10th ribs and cartilage. Furthermore, the tumor has protruded out of the ribs and costal plane, resulting in a bulging chest wall. The tumor blood supply was not abundant.
Figure 1: Three-dimensional reconstruction of giant tumor of thoracic cavity and thoracic organs (a, c and d) anterior view; (b) lateral view. Ri: Rib; Lu: Lung; St: Sternum; Ti: Three-dimensional titanium plate which should be designed; Tu: Giant tumor of thoracic cavity; Ca: Cartilage; Tr: Trachea; Bro: Bronchus; Rii: Ribs in the tumor

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According to 3D reconstruction of CT images, we knew the tumor size and defined the area and spatial shape of the chest wall that was intended to be removed. The 3D shape of the titanium plate was determined, and surgical program was clearly designed before the operation.

In operation, we successfully removed the tumor and repaired the chest wall. The size of the resected tumor was 30 cm × 25 cm × 15 cm. The titanium implants based on the 3D model was completely anastomotic with the resected area. The patient had 800 mL blood loss, good postoperative recovery without complications of bleeding, pneumothorax, and abnormal breathing [Figure 2].
Figure 2: Resection surgery of giant tumor and reconstruction surgery of chest wall. (a) Resection surgery of giant tumor; (b) huge defect in chest wall after tumor dissection; (c) Implantation of three-dimensional titanium plate in the chest wall; (d) Suture of thoracic skin

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Reconstruction of 3D CT scan image 2 days after the surgery showed that 3D printed titanium plate was completely anastomotic with the defect area of the chest wall. There was no displacement at the surgical repair area [Figure 3].
Figure 3: Three-dimensional reconstruction based on computed tomography images 10 days after surgery. (a) Anterior view; (b) left view

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  Discussion Top


3D printing has been widely used in medicine, including orthopedics, plastic surgery, maxillofacial surgery, dentistry, and urology. Surgery-associated structures can be printed out in three dimensions, which can assist 3D surgical diagnosis and surgical rehearsal. Fang et al. conducted 3D printing of giant liver cancer and the adjacent hepatic artery, portal vein branch, and hepatic vein branches. The printed 3D structure was used for surgical rehearsal, which improved the surgical resection efficacy and reduced complications, for example, postoperative bleeding and bile leakage.[4] Yu et al. established 3D model of cervical and thoracic vertebrate-based on consecutive CT scan for a 70-year-old patient with intraspinal tumors. Based on RE principles, the best path to insert the nail to pedicle was identified. In the subsequent operation, the study found that the positioning template was completely anastomotic with the posterior part of the vertebral body. Through the navigation hole, neck cervical thoracic pedicle was located, and the screws were successfully placed in the pedicle.[13]

Although 3D technology has been applied in many medical areas, it is still controversial for the application of 3D printed implant in surgery. Titanium alloy material has been approved by Chinese Food and Drug Administration (FDA), but 3D printed product of titanium has not been approved by FDA. Therefore, utilization of this 3D printed product has medical risks including mechanical strength, toughness, durability, etc., and it also lacks biomechanical experiment support. Use of 3D printed aid titanium is necessary and feasible because titanium plate is the end product and has been approved by FDA.[9]

The application of 3D printing in cardiothoracic surgery is still in its infancy, although some medical cases about 3D printing were reported.[11],[14],[15] The hospital of University of Salamanca, Spain, entrusted Anatomics medical device company in Melbourne, Australia, to make a very complex structure of titanium component for a male patient with malignant chest wall sarcoma and implanted it into the patient. The therapeutic efficacy was excellent, but the cost of the metal printer (Arcam with price of $1.3 million) and printing cost was very high. Thus, there were not many cases in which 3D printing was applied in cardiothoracic surgery.

In cardiothoracic surgery, operations on chest wall defect are challenging for the surgeons. Usually, the surgery titanium plate is flat, rectangular, and does not match the defect of the bone. It also does not fit the chest cavity and is easy to shift and wear out the skin. In this study, titanium plate formed by 3D printing completely fits the 3D shape of the chest wall. Consequently, it is less prone to dislocation or displacement, and there is no repeated friction with the chest wall during respiratory motion that may cause local damage on the chest wall. Furthermore, it has an attractive appearance after the surgery. The patients' bleeding can be reduced by 2000 mL compared to traditional surgery. In this study, the patient only had 800 mL bleeding, which largely reduced the patient's transfusion costs and the risk caused by blood transfusion. The surgery recovery time of the patient was also reduced from 2 weeks to 1 week.

In this study, we applied 3D digital navigation and 3D printing technology in cardiothoracic surgery, which would help carry out complex thoracic surgery, develop cardiothoracic surgery plan, improve the efficacy of surgery, shorten the operation time, and reduce the frictions on the residue sternum, ribs, chest wall muscle, and pleura caused by the conventional steel implant. Application of 3D printing also reduced the occurrence of complications, for example, bleeding, and abnormal breathing. Furthermore, the implant designed by 3D printing can not only fill the chest wall but also protect the thoracic contents, for example, heart and lung. Therefore, it is fully feasible to design individual 3D implant based on 3D printing for patients with chest wall defect.

In summary, successful completion of 3D printing assisted thoracic surgery in this study demonstrated that 3D printing will not doubt become an important method of personalized and digital medicine. With technological progress, implementation of 3D printing-assisted medicine will create more benefits for patients, hospitals, and even the whole society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Ma B, Kunz M, Gammon B, Ellis RE, Pichora DR. A laboratory comparison of computer navigation and individualized guides for distal radius osteotomy. Int J Comput Assist Radiol Surg 2014;9:713-24.  Back to cited text no. 12
    
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Yu H, Wang H, Cao Z, Liu Y, Hou M. Digital guiding plate in application of posterior tumor resection and decompression of cervical and thoracic spinal canal and posterior pedicle screws fixation. Med Pharm J Chin Peoples Liberation Army 2015;27:29-31.  Back to cited text no. 13
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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